Vital Signs: Nursing Practices and Assessment

• Vital signs are key indicators of a person's well-being
• Appropriate nursing practices regarding vital signs are important

Purposes of Understanding Vital Signs

• Identify vital signs
• Evaluate what normal values of vital signs are
• Measure and evaluate vital signs

Contents of Vital Signs

• Body temperature is one of the vital signs
• Pulse is one of the vital signs
• Respiration is one of the vital signs
• Oxygen saturation is one of the vital signs
• Blood pressure is one of the vital signs

Vital Signs Basics

• Vital signs provide an overview of an individual's health.
• Changes in vital signs can occur for many reasons such as:
  • Time of day
  • Age
  • Ovulation state
  • Seasons
  • Physical activity
  • Dressing or clothing type
  • Environmental heat
  • Stress
  • Disease

Guidelines on Assessing Vital Signs

• Nurses should know how to find vital signs, evaluate them, and communicate them to team members
• Equipment should be reliable
• Equipment should match patient's characteristics
• Normal vital sign values should be known
• Patient's medical history should be known
• Environmental factors should be kept in mind

Measuring Vital Signs

• Vital signs require systematization when they are measured at regular intervals.
• The nurse should be able to communicate effectively with the patient when measuring vital signs
• The nurse should cooperate with the physician
• When vital signs are measured, they should be analyzed absolutely

Frequency of measuring vital signs

• When preparing the patient for admission
• Before and after surgery
• Before and after diagnostic procedures
• Before and after administering drugs that affect the heart and respiratory system
• If there is sudden deterioration of the patient's condition
• Before and after medical interventions that may affect life signs
• When the patient reports feeling unwell

Body Temperature Basics

• Body temperature shows heat producted and heat consumed
• HEAT PRODUCTION - HEAT LOSS = BODY TEMPERATURE

Balanced Temperatures

• The body temperature should be consistent and balanced
• Heat production and heat consumption in the body must be equal
• Heat is produced through food
• Heat is lost through the lungs(breathing), the skin(sweating), and the body's waste (urine, vomiting, blood)
• Factors affecting temperature include:
  • Age
  • Exercise
  • Hormone level
  • Stress
  • Environment
  • Emotional states
  • Basal metabolic rate
  • Digestion of food
  • Nutrition and sleep
  • Diseases
  • Induction of sympathetic nervous system

Regulation of body temperature

• The thermoregulation center is the hypothalamus.
• The hypothalamus acts as a thermostat
• Regulation includes:
  • Vazodilation which causes a decrease in heat
  • Sweating
  • Muscle tremors which increase heat
  • Piloerection

Temperature Changes

• Hypothermia occurs when the body temperature is 35°C and below
• Hyperthermia occurs when the body temperature is above 38°C

Normal Temperatures

• Average oral temperature is 37°C
• Average ear temperature is 37°C
• Average axillary/forehead temperature is 36.5°C
• Average rectal temperature is 37.5°C

Measurement of body temperature

• Use a thermometer, digital is commonly used

Glass Thermometers

• The Environmental Protection Agency (EPA) states mercury poses a threat to humans
• Glass thermometers should not be used
• Their use was forbidden by Ministry of Health in 2009

Thermometer Types

• Thermometers come in multiple forms for measuring the individuals temperature

Measuring Body Temperature

• Hands are to be washed and gloves worn
• Every application of temperature taking uses prepared materials, should inform the patient, ensure they are comfortable and have their permission

Oral measurement of temperature

• Degrees are marked right or left under thetongue
• A typical oral measurement is 36.5°C - 367.5 °C

Oral Temperatures

• Should not be taken for patients with dyspnea, or for children and the elderly
• Should not be taken for patients with psychiatric diseases, or who are non-conscious
• Should not be taken post-surgery
• Should not be taken for mouth operations or infections
• Should not be taken for patients on continuous oxygen

Oral Temperature Key Points

• The patient should have their personal thermometer.
• Do not eat or drink anything with extreme temperatures before measurement
• The thermometer should be placed under the tongue
• The mouth should be closed to take an accurate reading

Tympanic Temperature

• A tympanic temperature is made within 1-2 seconds.
• The receiver is placed in the 1/3 of the outer ear
• Before measurement, a disposable plastic cover should be placed over the receiver.

Rectal measurement

• This temperature should be used when heat can not be taken by oral or axillary route
• Before measuring:
  • close the curtains
  • put the patient in sim's position
  • wear gloves
  • lubricate the probe
  • separate the patient's hips
  • insert into anus
  • remove when sounds

Temperatures not to be taken

• Do not take rectal temperatures on patients with rectal bleeding, rectum surgeries or during birth or maternity
• Do not use on children
• Do not use on Diarrhea patients

Axillary Measurements

• The axillary region is the most commonly used region for temperature taking
• Infection is considered unlikely to be transmitted
• The patient should have a personal thermometer
• The armpit should not be sweaty

Forehead Measurements

• A digital thermometer reads the surface of the forehead to give a temperature reading

Pulse

• The pulse is how many heartbeats occur per minute

Assessing Pulse

• While assessing the pulse should involve assessing the general qualities
• Assessing rate
• Assessing rhythm
• Assessing volume

Why count the pulse?

• It helps decide the rate, rhythm, and strength, contraction
• It helps identify peripheral vascular diseases

Pulse rate

• Newborn - 120-160/MIN
• Children - 80-120/MIN
• Adult - 60-100/MIN.

Pulse Indicators

• Bradycardia indicates pulse is below 60 beats per minute
• Tachycardia: indicates pulse rate is above 100 beats per minute

Factors affecting pulse rate

• Exercise
• Hyperthermia
• Hypothermia
• Acute pain and anxiety
• Chronic pain
• Drugs
• Age
• Gender
• Metabolism
• Bleeding
• Posture change

Pulse Rhythms

• If heart beats are regular rhythm then it is called regular rhythm and visa versa
• If there is arrhythmia, the difference between apical pulse and radial pulse should be checked
• Deficit (Pulse deficit) develops a difference between the apical and pulse rate
• periphernal pulse indicates an arrhythmia

Radial Pulse

• During even contraction pulses do not reach periphery

Pulse Volume

• The pulse volume as well as contraction also reflects the heart
• Normally the pulse is easily found if every beat is felt similar
• Weak pulses are hard to find even with finger pressure to the point the pulse dissipates that is known as a thready pulse

Pulse points

• Temporal artery (above the zygomatic arch, above and in front of the tragus of the ear)
• Carotid artery (next)
• Apical (on the midclavicular line, in the fifth intercostal space)
• Radial artery (wrist)
• Ulnar artery (wrist)
• Brachial artery (medial border of the humerus)
• Femoral artery (at the groin)
• Popliteal artery (behind the knee)
• Dorsalis pedis (on foot)
• Posterior tibial arteries (near the ankle joint) foot

Emergency Pulse Points

• 0–1 age; apical / brachial/femoral artery,
• 1 age; carotid artery

Peripheral pulse taking

1. Wash hands
2. Verification is done/checks
3. Communicate with the patient and inform them of application
4. Evaluate the factors that will affect the condition and pulse rate
5. The patient should not be standing and should be rested
6. The patient should be given a proper position
7. The sign, middle, and ring finger are placed on the artery without excessive pressure
8. If the pulse is measured for the first time and is irregular, it is counted for 1 minute. If it is regular, it is counted for 30 seconds and multiplied by two
9. Recorded the findings

Respiration

• Organs of the respiratory system include:
  • Nose
  • Pharynx
  • Larynx
  • Trachea
  • Bronchi
  • Lungs

Human respiratory system

• Respiration is a process that starts with breathing with involve using O2 and relates CO2 from the human organisms'
• Inhalation
• Exhalation

Different stages

• It needs to between the lungs which gets O2 into our blood to the circulatory system or the respiratory system itself to exchange with the other organism

Ventilation, difussion and perfusion

• The respiratory center is found medulla oblongata and Pons in the brainstem

Respiratory measurements

• This require understanding measurements
• Inpsect the rates
• Inspect the depth

Respiratory rate standards

• Newborns = 30-60/min rate of breath
• Adults 12 -20/min rate of breath

Respiratory depths

• Respiratory depth is measured by deep, superifical and normal assessments
• This depth can be affected by body position, medications, exercise, fear and anxiety
• The diaphragm increases normally by 1 cm
• The costa extends 1.5-2.5cm forward

Types of respiration

• Hyperventilation
  • increased rate and depth of breathing
• Hypoventilation
  • decreased rate and depth of breathing
  • irregular

Anoxia hypoxia and dyspnea

• Anoxia or absecnce oxygen is needed to regulate breath
• Hypoxia need oxygen to prevent cell and tissue damage
• Dypnea to have the body not have a difficult time breathing

Breathing observations and counting

• Observe the rate and rhythm by seeing the chest rise and fall
• Each rise and fall is a respiration, that is why we count a minute for respiration rates to be accurate to prevent saying anything to the patient.
• Do not tell the patient what are you doing

Process of breathing

1. Gather the materials
2. Make the patient confortable
3. Wash your hands
4. Evaluate patient's exercise, eating, and fatigue
5. The rib has to be able to be observed

More steps

1. Check your watch
2. Expirations/Inspirations count as is
3. If steady, count for 30 seconds and multiple by 2.
4. If uneven cont for 1 minute and make an average
5. Take note of the depth
6. Position the patient
7. Put away tools
8. Wash hands
9. Record data
10. Prevent anormalities

Oxygen Saturation

• Pulse oximetri helps in the process of measuring oxygen saturation of the blood
• Noninvasive/painless
• Provides an overview of if oxygen can reach needed tissues such as fingers and other external regions

Types of instruments

• Measure the maximum oxygen within rich blood vessels
• Normal levels are 95-100 % in ideal conditions
• If under 90% low levels

Oxygen placements

• Probes should be on the fingers or somewhere that are not affected by outside
• The finger has a light sourse that probes the blood's saturation levels

Blood Pressure

• Blood pressure is measure of the force that heart uses to move the blood with in body
• Systolic pressure measures force moving out of the heart
• Diastolic measures force moving in to the heart
• Ideal measure is less than 120/80

Ideal Blood Pressure

• An ideal blood pressure to have is between 90/60mmHG and 120/80 mmHG
• High is indicated from 140/90mmHG which if the patient is at hypertension.

Pulse Pressure

• Pulse pressure is measuring the variance in the systolic and diastolic pressures.
• 30-50mmHG is ideal

Affecting Factors

• Factors affecting blood pressure
  • Age, Stress, Daily Life, Race, Medicines, Gender, Drugs, Foods and, Exercise

Hypertension/Hypotension

Hypertension- World health organization value in human being 1-40/90/mmHG

Hypotension

Arterial blood pressure values can be measured using hypotension, it usually measured if systolic blood pressure is or below 90mmHG

Hypotension observations

• Check the pulse and the values as well with the tools
• To measure you must to have
  • sphygomanometer/ Blood Pressure Monitor
  • Stethoscope disinfectant, pin, waster container
  • The measurement relies on the arm
  • The arm has to steady when it's being taken
  • Anxious patient will have varying rate

Measurement

Requires supine position along with a fowler along the side with the pressure along the side

• It can be the position

Actions to ensure accuracy

• To ensure accuracy, use appropriate side and placement of the arm
• Use the right equipment

Check the tool

• Check the equipment to make sure if equipment
• The patient needs to be seated with correct pulse to
• If the situation is brand then measure the other
• Follow rules values by not moving of your part as human while checking it